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The Orissa Entry Tax - Forms
-

FORM E37

[See rule 30 (3)(a)]

APPLICATION FOR REFUND OF TAX

01. Office address :  
  .................................................................

.................................................................

.................................................................

 
Date Month Year
     
 
 

02. TIN/SRIN/Identification No.
 
 
03. Name & address of the dealer:  
  -------------------------------------  
  -------------------------------------  
  -------------------------------------  

(Use separate sheet if the space provided is found inadequate)

04. Tax Period(s) From
Date Month Year
     
 		 To
Date Month Year
     
 

05. Value of goods exported out of the territory India
Rs.
 
06. Value of goods for which deduction/exemption claimed under the Orissa Entry Tax Act & Rules (please specify)
Rs.
 
 
 
07. Amount of Entry Tax due for refund as a result of transaction mentioned in Para 05 & o6 above
Rs.
 
08. Evidence in support of claim of Export and Deduction/exemption (copies of document to be enclosed)
Rs.
 
 
 
09. The basis on which the amount of refund of Entry tax has been claimed (Documentary evidence, if any, to be enclosed)
1.

2.

3.

4.

5.

 
10. DECLARATION

I, Sri_____________________________ status___________________ of the business ___________________________ at________________________ bearing TIN/SRIN/IDENTIFICATION NO. .............................................., do hereby declare that what is stated in this form is true and correct to the best of my knowledge and belief. I also further declare that the amount of refund claimed above has been paid by me and that the amount or any part thereof has not been realized by me by way of tax or otherwise from any person or persons.

Place _____________ Signature
   
Date _____________  
  (Seal)